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OBSTETRICAL POLICY Policy Number: ADMINISTRATIVE 200.17 T0 Effective Date: October 1, 2017

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UnitedHealthcare® Oxford Reimbursement Policy OBSTETRICAL POLICY Policy Number: ADMINISTRATIVE 200.17 T0 Effective Date: October 1, 2017 Table of Contents Page Related Policies INSTRUCTIONS FOR USE .......................................... 1 Assistant Surgeon Policy APPLICABLE LINES OF BUSINESS/PRODUCTS .............. 1 Global Days Policy APPLICATION .......................................................... 1 Increased Procedural Services Policy OVERVIEW .............................................................. 1 Multiple Procedures Policy REIMBURSEMENT GUIDELINES .................................. 2 DEFINITIONS .......................................................... 8 APPLICABLE CODES ................................................. 9 QUESTIONS AND ANSWERS ...................................... 9 ATTACHMENTS ....................................................... 10 REFERENCES .......................................................... 11 POLICY HISTORY/REVISION INFORMATION ................ 11 INSTRUCTIONS FOR USE The services described in Oxford policies are subject to the terms, conditions and limitations of the member's contract or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage members. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise required by Oxford's administrative procedures or applicable state law. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies. Certain policies may not be applicable to Self-Funded members and certain insured products. Refer to the member specific benefit plan document or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the member specific benefit plan document or Certificate of Coverage, the member specific benefit plan document or Certificate of Coverage will govern. UnitedHealthcare may also use tools developed by third parties, such as the MCG™ Care Guidelines, to assist us in administering health benefits. The MCG™ Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice. APPLICABLE LINES OF BUSINESS/PRODUCTS This policy applies to Oxford Commercial plan membership. APPLICATION This policy applies to all network and non-network physicians and other qualified health care professionals, including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals. OVERVIEW Maternity care includes antepartum care, delivery services, and postpartum care. This policy describes reimbursement for global obstetrical (OB) codes and itemization of maternity care services. In addition, the policy indicates what services are and are not separately reimbursable to other maternity services. Unless otherwise specified, for the purposes of this policy Same Group Physician and/or Other Health Care Professional includes all physicians and/or other health care professionals of the same group reporting the same federal tax identification number. Obstetrical Policy Page 1 of 11 UnitedHealthcare Oxford Reimbursement Policy Effective 10/01/2017 ©1996-2017, Oxford Health Plans, LLC Oxford may allow a newly enrolled woman to continue maternity care on an in plan basis with a non-participating provider. This is referred to as Transitional Care. This will most likely result in a prorated claim. REIMBURSEMENT GUIDELINES Global Obstetrical (OB) Care As defined by the American Medical Association (AMA), "the total obstetric package includes the provision of antepartum care, delivery, and postpartum care." When the Same Group Physician and/or Other Health Care Professional provides all components of the OB package, report the global OB package code. The Current Procedural Terminology (CPT®) book identifies the Global OB codes as: 59400 - Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care 59510 - Routine obstetric care including antepartum care, cesarean delivery and postpartum care 59610 - Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous cesarean delivery 59618 - Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery Oxford reimburses for these global OB codes when all of the antepartum, delivery and postpartum care is provided by the Same Group Physician and/or Other Health Care Professional. Oxford will adjudicate claims submitted with either a single date of service or a date span when submitting global OB codes. To facilitate claims processing, a single date of service may be utilized. Please refer to the Itemization of Obstetrical Services section of this policy for guidance on coding services when a patient changes insurers or group practices during her pregnancy. Services Included in the Global Obstetrical Package Per CPT guidelines and the American Congress of Obstetricians and Gynecologists (ACOG), the following services are included in the Global OB package (CPT codes 59400, 59510, 59610, 59618): All routine prenatal visits until delivery (approximately 13 for uncomplicated cases) Initial and subsequent history and physical exams Recording of weight, blood pressures and fetal heart tones Routine chemical urinalysis (CPT codes 81000 and 81002) Admission to the hospital including history and physical Inpatient Evaluation and Management (E/M) service provided within 24 hours of delivery Management of uncomplicated labor Vaginal or cesarean section delivery (limited to single gestation; for further information, see Multiple Gestation section) Delivery of placenta (CPT code 59414) Administration/induction of intravenous oxytocin (CPT codes 96365 - 96367) Insertion of cervical dilator on same date as delivery (CPT code 59200) Repair of first or second degree lacerations Simple removal of cerclage (not under anesthesia) Uncomplicated inpatient visits following delivery Routine outpatient E/M services provided within 6 weeks of delivery Postpartum care only (CPT code 59430) Oxford will not separately reimburse the above services when reported separately from the global OB code. Exceptions: Participating and non-participating New Jersey providers may elect to be reimbursed for maternity services rendered to a covered person enrolled with a New Jersey line of business on either a global (one payment for all services rendered during the term of the pregnancy for antepartum care, delivery and postpartum care) or on an installment basis (3 equal payments that when combined are the equivalent of the global payment for services rendered during the term of the pregnancy) for pregnancies that begin January 5, 2012 and after. If a non-participating provider in New York is eligible for a global payment and payment is requested before delivery, two dates of service prior to delivery may be reimbursed. Per ACOG coding guidelines, reporting of third and fourth degree lacerations should be identified by appending modifier 22 to the global OB code (CPT codes 59400 and 59610) or delivery only code (CPT codes 59409, 59410, 59612 and 59614). Claims submitted with modifier 22 must include medical record documentation that supports the Obstetrical Policy Page 2 of 11 UnitedHealthcare Oxford Reimbursement Policy Effective 10/01/2017 ©1996-2017, Oxford Health Plans, LLC use of the modifier; please refer to the Increased Procedural Services section of this policy and Oxford's Increased Procedural Services policy. Services Excluded from the Global Obstetrical Package Per CPT guidelines and ACOG, the following services are excluded from the Global OB package (CPT codes 59400, 59510, 59610, 59618) and may be reported separately if warranted: Initial E/M to diagnose pregnancy if antepartum record is not initiated at this confirmatory visit. This confirmatory visit would be supported in conjunction with the use of ICD-10-CM diagnosis code Z32.01 (Encounter for pregnancy test, result positive). Laboratory tests (excluding routine chemical urinalysis) Maternal or fetal echography procedures (CPT codes 76801, 76802, 76805, 76810, 76811, 76812, 76813, 76814, 76815, 76816, 76817, 76820, 76821, 76825, 76826, 76827 and 76828). For additional information, see E/M Service with an Obstetrical (OB) Ultrasound Procedure section. Amniocentesis, any method (CPT codes 59000 or 59001) Amnioinfusion (CPT code 59070) Chorionic villus sampling (CVS) (CPT code 59015) Fetal contraction stress test (CPT code 59020) Fetal non-stress test (CPT code 59025) External cephalic version (CPT code 59412) Insertion of cervical dilator (CPT code 59200) more than 24 hours before delivery E/M services for management of conditions unrelated to the pregnancy (e.g., bronchitis, asthma, urinary tract infection) during antepartum or postpartum care; the diagnosis should support these services. For further information please refer to the Non-Obstetric Care section of this policy. Additional E/M visits for complications or high risk monitoring resulting in greater than the typical 13 antepartum visits; per ACOG
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